Last Word: Mr Norman Waterhouse

By: Mr Norman Waterhouse
Created on 12th January 2010

Norman Waterhouse, one of the UK's leading surgeons in aesthetic facial plastic surgery, reasons why minimal doesn't always translate into maximum results

Minimus. My daughters introductory Latin textbook bears this title. it means ‘very small' or ‘the smallest'. As with all Latin, care has to be taken in translating comparative adjectives and adverbs. So, parvus means small and minor means smaller. However, ‘little' ‘less' and ‘least' or ‘very little' are paulum, minus and minime respectively.

These subtle differences in meaning led me to ask what we mean when aesthetic surgery techniques are described as ‘minimal'.

Minimally invasive, minimal access, mini tuck and mini lifts are words we hear all the time and are increasingly used to suggest that the procedure is at the cutting edge of surgical technology. ‘Mini' applied in any way is attractive, as it implies quick recovery and downtime.

There have been huge advances in reducing the impact of surgical procedures with the use of endoscopic instruments and small incisions. I am writing this article as I recover from surgery to my shoulder for a rotator cuff tear, and am delighted and impressed that the repair was carried out through a few tiny incisions without having to cut through all the shoulder muscles! However, the means of repairing the tendons was as complicated and effective as it would have been with the joint open.

The use of the endoscope in aesthetic surgery has all but eliminated the need for an open brow incision. Here again, note that although the means of performing the surgery has changed, the surgical manoeuvres are the same.

So, minimal access does not mean that the technical gestures are less. Minimally invasive has been used to mean the same thing as minimal access but more implies less actual surgical dissection and that this also represents a surgical advance.

Mini as applied to abdominoplasty or facelift can mean almost anything and is often lumped in with terms such as lunchtime lifts and soft lifts. As an American plastic surgeon once said to me, "Surgeons like surgery a whole lot more than patients do", and I do not wish to suggest that I am resistant to developing new techniques which minimise the impact of surgery. However, I am anxious that there is an assumption that minimal surgery is necessarily as good or better than established procedures.

Facelift surgery is an excellent illustration. Modern advances have allowed effective techniques to be performed through smaller scars and better scar placement. Quicker recovery has resulted from improvement in anaesthesia, the use of local anaesthetic infiltration and more control over post-operative care. In order to produce an effective and natural, long lasting rejuvenation, however, the surgery itself has to include meaningful gestures.

It is quite wrong to assume that if a procedure is ‘minimal', it will be effective. Regrettably, the truth is that for the most part the results achieved by minimal surgery are, well, ‘minimal'.

At an international conference in Rio a few years ago, I asked the audience of over a thousand surgeons if anyone had seen or could show comparative photographs before and six months after a ‘thread lift' that demonstrated a clear benefit. No one could and I am still waiting.

In presenting information to the public, honesty is important. It is essential to explain to anyone undergoing a facelift that downtime is inevitable as is some swelling and bruising. Equally, the limitations of a small procedure must be honestly presented.
In choosing a surgical procedure for our patients, I believe we should not overplay the minimus but choose the optime. The best!
CS&AM